1 The Royal Marsden Women's cancers Breast cancer introduction Women's cancers Breast cancer introduction 3 Epidemiology, aetiology and the patient pathway in oesophageal and pancreatic cancers Dr Ian Chau Consultant Medical Oncologist The Royal Marsden What profession are you in? 1) Academic general practice 2) Non-academic general practice 3) Nursing 4) Managerial 5) Others The Royal Marsden Put in order the commonest cause of cancer death worldwide A) colorectal cancer B) breast cancer C) gastric cancer D) lung cancer E) hepatocellular carcinoma Answers: Vote 1 D, B, A, C, E Vote 2 B, D, A, E, C Vote 3 D, C, E, A, B Vote 4 D, E, A, C, B
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The Royal Marsden
Women's cancers Breast cancer introductionWomen's cancers Breast cancer introduction 3
Epidemiology, aetiology and the patient pathway in oesophageal and pancreatic cancers
Dr Ian Chau
Consultant Medical Oncologist
The Royal Marsden
What profession are you in?
1) Academic general practice
2) Non-academic general practice
3) Nursing
4) Managerial
5) Others
The Royal Marsden
Put in order the commonest cause of cancer death worldwide
A) colorectal cancer
B) breast cancer
C) gastric cancer
D) lung cancer
E) hepatocellular carcinoma
Answers:
Vote 1 D, B, A, C, E
Vote 2 B, D, A, E, C
Vote 3 D, C, E, A, B
Vote 4 D, E, A, C, B
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Match the five-year survival rate with the following cancer in the UK
GLOBOCAN 2008 (IARC); Cancer Research UK CancerStats accessed July 2013
Cancer Oesophagus Stomach Pancreas Liver
World incidence 481,000 988,000 278,000 749,000
World mortality 406,000 736,000 266,000 694,000
World ranking of cancer-related deaths
6th 2nd 7th 3rd
UK incidence 8,477 7,266 8,463 4,241
UK mortality 7,610 4,960 7,901 3,789
UK 5-year survival 13% 17.9% 3.7% 5.5%
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Oesophageal Cancer Epidemiology UK
– Incidence of oesophageal cancer rises with age
– More common in males than females
– Incidence in males continues to rise whereas incidence in
female started to fall at the turn of the century
Cancer Research UK CancerStats accessed July 2013
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Percentage distribution of cases in oesophageal cancer, UK 2008-2010
Cancer Research UK CancerStats accessed July 2013
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Risk factors for oesophageal cancer
– 2 types of cancer of the oesophagus: squamous cell carcinoma and adenocarcinoma.
– Adenocarcinoma of the oesophagus is increasing rapidly in Western populations but the underlying reasons for this are unclear.
– Tobacco use increases the risk of both types of oesophageal cancer.
– Alcohol consumption increases the risk of squamous cell carcinoma of the oesophagus.
– Some of the highest risks of squamous cell carcinoma of the oesophagus occur in people who combine a smoking habit with regularly drinking alcohol.
– Around two-thirds of oesophageal cancers in the UK are caused by smoking and around one-fifth are linked to alcohol.
– Being overweight or obese (→ ↑acid reflux) - ↑ risk of adenocarcinoma of the oesophagus.
– One of the strongest risk factors for adenocarcinoma of the oesophagus is the pre-cancerous condition known as Barrett’s oesophagus.
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Pancreatic Cancer Epidemiology UK
– Incidence of pancreatic cancer rises with age
– Similar incidence in males and females
– Incidence generally stable although there is a small decline in
males
Cancer Research UK CancerStats accessed July 2013
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Which risk factor is the most important for pancreatic cancer in the UK?
1) Type 2 diabetes
2) Type 1 diabetes
3) Chronic pancreatitis
4) Smoking
5) Obesity
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Risk factors for pancreatic cancer
– About 30% pancreatic cancers in the UK are caused by smoking.
– People with type I or II diabetes have roughly twice the risk of developing pancreatic cancer.
– Chronic pancreatitis is associated with increased risk of pancreatic cancer.
– Being overweight or obese increases the risk of pancreatic cancer, with around 1,000 cases in the UK each year linked to excess bodyweight.
– Eating processed meat may increase risk of pancreatic cancer.
– People with a family history of pancreatic cancer have a higher risk of developing the disease
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Case history 1
– 62 years old male
– Jan 09 presented with dyspepsia
– OGD showed malignant lesion from 39-46cm
– Biopsy → poorly differentiated signet ring
adenocaricnoma
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T3N1M0
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Case history 1 (cont’d)
– EUS → T3N1 type 1 OGJ adenocarcinoma with extension below the OGJ
– Laparoscopy → no peritoneal disease, no evidence of disease even at OGJ
– Mar to May 09 Randomised in OEO 5 study to have pre-operative ECX
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Oesophago-gastric cancer: patient pathwayTypical symptoms: Dysphagia, dyspepsia, weight loss
Upper GI endoscopy
Cancer suspected
Histology
CTMetastatic disease
Palliative chemotherapy
Localised disease
Endoscopic ultasound
PET
Laparoscopy
Peri-operative treatment +
Surgery
HER 2 testing
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Multimodality treatment for resectable oesophageal cancer
Squamous cell carcinoma Adenocarcinoma
Definitive
chemoradiation
Pre-operative
chemoradiation
Surgery
Pre-operative
chemotherapy
Surgery
Pre-operative
chemoradiation
Surgery
Oesophagus Oesophago-
gastric junction
Pre-operative
chemotherapy
Surgery
Post-operative
chemotherapy
Surgery
Post-operative
chemoradiation
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Multimodality treatment in operable gastric cancer
Pre-operative
chemotherapy
Surgery
Post-operative
chemotherapy
Surgery
Post-operative
chemoradiation
Surgery
Post-operative
chemotherapy
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UK Second National Oesophago-Gastric Cancer
Audit 2013
– National audit for all patients diagnosed between 1
Apr 2011 and 31 mar 2012 with OG cancer in England
and Wales
– Data on 11,516 pts submitted
– Overall 35% of patients had curative treatment plan
The Royal College of Surgeons, National Oesophago-Gastric Cancer Audit 2013
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Proportion of tumours diagnosed by location
Oesophagus 47.3%
OGJ 22.7%
Stomach 30.0%
The Royal College of Surgeons, National Oesophago-Gastric Cancer Audit 2013
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What proportion of patients with newly diagnosed oesophago-gastric cancer was referred initially by GP?
1) Two-thirds
2) Three-quarters
3) One-tenth
4) 100%
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Of the patients with newly diagnosed oesophago-gastric cancer who was referred initially by GP, what proportion was referred in as an urgent suspected cancer?
1) 10%
2) 30%
3) 50%
4) 70%
5) 90%
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Patterns of referral
Total Oesophageal Stomach + OGJ
GP referral 67% 71% 56%
Emergency admission 15% 11% 25%
Referral from another hospital consultant18% 18% 19%
- Of the GP referrals, 71% were referred as USC: 74% oesophageal vs. 64% stomach; p<0.0001- Patients presented as emergency admission were less likely to have a radical treatment plan
The Royal College of Surgeons, National Oesophago-Gastric Cancer Audit 2013
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Oesophago-gastric cancer: patient pathway
Typical symptoms: Dysphagia, dyspepsia, weight loss
Upper GI endoscopy
Cancer suspected
Histology
CTMetastatic disease
Palliative chemotherapy
Localised disease
Endoscopic ultasound
PET
Laparoscopy
Peri-operative treatment +
Surgery
HER 2 testing
The Royal Marsden
National audit OG cancer: patient pathway (n=17,279)
Typical symptoms: Dysphagia, dyspepsia, weight loss
Upper GI endoscopy
Cancer suspected
Histology
CT
(91%) Metastatic disease
Palliative chemotherapy
Localised disease
Endoscopic ultasound (62%)
PET
Laparoscopy (57%)
Peri-operative treatment +
Surgery
HER 2 testing
84% had either EUS or PET
The Royal College of Surgeons, National Oesophago-Gastric Cancer Audit 2013
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Planned Rx Oes SCC Oeso Adeno Oeso Adeno OGJ Stomach
Upper/Mid Lower/S1 SII/III
Surgery alone 12% 22% 18% 21% 47%
(Total: 25%)
RT alone 10% 5% 4% 2% 1%
(Total: 4%)
Chemo + surgery 35% 55% 62% 70% 46%
(Total: 54%)
Definitive chemorad 38% 8% 8% 3% 2%
(Total: 11%)
ChemoRT + surgery 3% 1% 2% 1% 1%
(Total: 2%)
EMR 2% 9% 6% 3% 4%
(Total: 4%)
UK National Oesophago-Gastric Cancer Audit 2013:
Curative treatment decisions
– Overall 35% of patients had radical treatment plan
The Royal College of Surgeons, National Oesophago-Gastric Cancer Audit 2013
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Of the patients with newly diagnosed oesophago-gastric cancer who could not be treated with curative intent, what proportion were treated with palliative care alone?
1) 20%
2) 40%
3) 60%
4) 80%
5) 100%
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Planned Rx Oes SCC Oeso Adeno Oeso Adeno OGJ Stomach
Upper/Mid Lower/S1 SII/III
Best supportive care 36% 40% 36% 36% 55%
(Total: 42%)
Palliative Oncology (chemotherapy or radiotherapy)